Provider Demographics
NPI:1659468999
Name:FREDERICKS, GAIL JUNE (MD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:JUNE
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:JUNE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:121 DIANA ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-3313
Mailing Address - Country:US
Mailing Address - Phone:530-559-2880
Mailing Address - Fax:530-622-2979
Practice Address - Street 1:121 DIANA ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-3313
Practice Address - Country:US
Practice Address - Phone:530-559-2880
Practice Address - Fax:530-622-2979
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61646208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A616460Medicaid
CA05D0932276OtherCLIA ID NO
CABR5213169OtherDEA REG NO
CA00A616460Medicare ID - Type Unspecified
CA00A616460Medicaid